Rethinking medical audit: the goal is efficiency.

Last year in this journal Hopkins' reviewed the various approaches to "medical audit", and looked at how such audit is likely to develop over the next few years. The essence of his article seems to be that medical audit, if successful, should improve the quality of care. However, Hopkins can provide no evidence that any of the three approaches to medical audit which he outlines achieves this objective. He notes that reviewing medical records "can only give a general impression of the quality of care in an institution"; that "the promulgation of guidelines of good practice does not necessarily change practice"; and that, while the provision of information systems "will almost certainly improve the quality of recording of hospital activity ... there is as yet no generally accepted view about what data sets are required to reflect usefully the quality of clinical care". Hopkins concludes that he "has taken a somewhat gloomy approach to the difficulties of medical audit". However, in an effort to be more optimistic, he states that in his view "the best audit package that a health district can at present institute may be a regular case record by an assessor, probably from a neighbouring district." And he continues that for all their drawbacks "such reviews have been shown to improve and maintain the quality. . ." not unfortunately, as we had hoped, of patient care but ". of the written record"! The three approaches to medical audit outlined by Hopkins involve only medical doctors. Clearly, if medical audit is only for doctors, then we, as economists, have no business writing about it. However, we would argue that since medical audit is about (or should be about) maximising benefits to patients with available resources, we have a role in discussing it. We want to comment on medical audit, since we believe that Hopkins has ignored two crucial questions. Namely, what is best medical practice? and how can doctors be got to practice it? Only by considering these two questions can we be sure that medical audit will increase the quality of health care or, as we would prefer to put it, the efficiency ofhealth care. In the absence of such questions we have no way of judging whether change brought about by medical audit improves or worsens medical practice. In the next section we discuss the concept of "best medical practice" and its importance to medical audit. Thereafter we examine how best medical practice, once defined, can be achieved, and finally we look at how medical audit is being implemented in the United Kingdom and suggest areas for future research and discussion. This paper should be of interest to all those involved in medical audit.